Critical Care Exam 3

1. Thorocentesis (should hear hissing sound) 2. Chest tube insertion to re-exapand.

What are some interventions for patients with tension pneumothorax?

1. Fluid resuscitation (prevent hypovolemic shock) 2. Chest tube management (remove blood) 3. Autotransfusion (for bleeding) 4. Thoracotomy

What are some interventions that can be used to help treat patients with hemothorax?

1. Increased Ammonia (neuro changes). 2. Increased Estrogen (gynecomastia, red itchy palms, spider angiomas). 3. Hyper or Hypoglycemia 4. Decreased Albumin (ascites, edema in legs). 5. Decreased Fibrinogen & Prothrombin (bleeding). 6. Decreased Vitamin K (bleeding). 7. Decreased Vitamin D (fractures). 8. Increased Bilirubin (Jaundice/Clay colored stools).

What are some laboratory findings you would anticipate in a patient with Cirrhosis?

1. Sudden midepigastric LUQ pain 2. Pain radiates to back & is worse when laying flat. 3. Pain occurs after eating fatty foods/drinking alc. 4. Tachycardia & Hypotension 5. Hyperglycemia 6. Cullen & Turner's Signs 7. Increased Amylase & Lipase 8. Fever 9. N/V

What are some manifestations of Acute Pancreatitis?

1. Ascites 2. Steatorrhea (oily stools) 3. Weight loss 4. Dark urine 5. Jaundice 6. DM 7. Fibrosis

What are some manifestations of Chronic Pancreatitis?

1. Asterixis (tremors in hands). 2. Esophageal Varices 3. Reduced Platelets & WBCs (infection risk). 4. Loss of appetite 5. Jaundice/Clay colored stools 6. Renal failure 7. Confusion/Coma 8. Ascites/Edema in lower extremities. 9. Red itchy hands/Spider angiomas/man boobs 10. Splenomegaly

What are some manifestations of Cirrhosis?

1. Decreased venous return. 2. Decreased CO & BP 3. Hypoventilation

What are some manifestations of increased IAP?

1. Reduced H&H 2. Increased urine output/Renal perfusion. 3. Hyponatremia 4. Hypokalemia 5. Hypoalbuminemia & Metabolic Acidosis may persist as they did before the resuscitation.

What are some manifestations seen during the intermediate phase of burn care/fluid resuscitation?

1. Sucking sound on inspiration. 2. Subcutaneous Emphysema. 3. Decreased CO & BP 4. Tachycardia

What are some manifestations that could be expected from a patient with open pneumothorax?

1. Tracheal deviation away from affected side. 2. Absent breath sounds on affected side. 3. Decreased CO & BP 4. Tachycardia

What are some manifestations that could be expected from a patient with tension pneumothorax?

1. Respiratory pattern changes. 2. Hoarsness/Brassy cough 3. Expiratory wheezing, crowing, stridor 4. Dysphagia

What are some possible indicators of emergent airway edema after burn injury?

1. Burns on ANY part of the face. 2. Smoky smelling breath 3. Singed nasal hairs 4. Black particles in nose, mouth, or sputum

What are some possible indicators of inhalation injury?

1. Unrelenting fever 2. Increased RR & HR 3. Bloating 4. Increased abdominal pain/guarding 5. Rebound tenderness

What are some potential indicators of Peritonitis?

1. Systolic BP <90 2. Narrowing pulse pressure 3. Tachycardia & Tachypnea 4. Decreased urine output 5. Cool/Clammy skin 6. LOC changes, irritability, anxiety

What are some signs of Hypovolemic shock?

1. Uneven legs or turned foot 2. Rocking of iliac crest 3. Hematuria 4. Perianal ecchymosis 5. Pain on palpation 6. Lower limb paresis

What are some signs of a pelvic fracture?

1. Circulatory collapse (from hypoperfusion) 2. Hypotension 3. Anuria 4. Respiratory distress 5. Acidosis 6. Unalert

What are some symptoms associated with irreversible shock?

1. High fiber diets (whole-grains, fruits, veggies). 2. Drink plenty of fluids. 3. Avoid foods with seeds & alcohol.

What are some ways to help prevent Diverticulitis?

1. Bradycardia 2. Visual disturbances 3. Piloerector response 4. Severe HA 5. Flushing 6. Diaphoresis

What are the expected Autonomic Dysreflexia symptoms ABOVE a spinal cord injury?

1. Sudden increase in BP 2. Pallor 3. Piloerector response (goosebumps)

What are the expected Autonomic Dysreflexia symptoms BELOW a spinal cord injury?

1. PSNS stimulation above injury 2. SNS stimulation below the injury 3. Bradycardia from vagus stimulation 4. Pale skin below the injury (remove TED hose)

What happens during Autonomic Dysreflexia?

1. Extreme vasodilation 2. Decreased CO, BP, & HR 3. Can happen early (24 hrs) or within month after spinal injury **Life Threatening**

What happens during Neurogenic Shock?

1. Flaccid paralysis 2. Immediate loss of reflexes 3. May be temporary or long-lasting

What happens during Spinal Shock Syndrome?

1. Tachycardia, Vasoconstriction, Fluid conservation. 2. Cool/Clammy skin. 3. Urine output may be normal or decreased. 4. Baseline MAP decreased by 10 mmHg. 5. Increased RR/Hypoxia 6. Restlessness/Anxiety

What happens during the early stages of shock?

Greater than 60

What is considered normal Abdominal Perfusion Pressure?

Achieving a urinary output of 0.5 mL/kg/hr.

What is the best indicator of successful fluid resuscitation in burn victims?

0.5 mL/kg/hr

What is the goal urinary output for a patient with burn injuries?

Manage inadequate tissue perfusion.

What is the most important goal of nursing care for a client who is in shock?

CT Scan

What is the most reliable diagnostic test to determine the severity of liver injuries?

0-5

What is the normal range for IAP?

0-5

What is the normal range for abdominal pressure?

Difuse axonal injury

What is the worst type of closed CNS injury?

Basilar skull fracture

What is the worst type of open type of CNS fracture?

1. Hypovolemia (fluid deficit) 2. Hypotension & Tachycardia 3. Hypoalbuminemia (from edema & weight gain). 4. Metabolic Acidosis 5. Hyperkalemia 6. Hyponatremia 7. Increased H&H (hemoconcentration) 8. Increased BUN (hemoconcentration)

What manifestations can be expected in a burn patient in the vascular/fluid shift phase during the first 12-36 hours after burn injury?

Jaw-thrust

What method is used to establish a patent airway in trauma patients during a primary survey?

Greater than or equal to 20.

What number signals intra-abdominal Compartment Syndrome?

Greater than or equal to 12.

What number signals intra-abdominal HTN?

1. Can exceed CVP 2. Decreased venous return/CO 3. Could lead to multiple organ dysfunction.

What results from increased intra-abdominal pressure?

"tidine"

What suffix do H2 blockers end with?

"prazole"

What suffix do PPI end with?

Duodenal

What type of ulcer has no Gastritis, is more likely to have Melena than hematemesis, & is relieved by ingesting food?

Crystalloids & Colloids

What types of fluids are used in fluid resuscitation of burn victims?

When wounds are healed & ends when the patient reaches optimal level of functioning.

When does the rehabilitative phase of burn management begin?

Hemorrhage (because of alterations in coagulation: vitamin K, fibrinogen, & prothrombin affected)

With trauma to the liver there is a high risk for _________________.

NG tubes

_________________ are contraindicated in facial trauma patients until ruled out by x-ray.

Escharotomy

__________________ is used to relieve thorax pressure in order to allow chest expansion/ventilation & can also be used to treat compartment syndrome in burn patients.

Curling's Ulcer

__________________ may occur within 24 hours of burn injury so patients should receive GI prophylaxis.

Fresh frozen plasma.

___________________ will likely be administered for patients with liver trauma.

1. Start IV infusion of Lactated Ringers. 2. Administer Morphine for pain. 3. Administer Tetanus prophylaxis as ordered

A 35 yr old client is brought to the ER with 2nd & 3rd degree burns over 15% of the body. Vitals show a BP of 100/50, HR 130, & RR 26. Which nursing interventions are appropriate for this client?

1. Decreased urinary output. 2. Hypotension & Tachycardia 3. Mental confusion 4. Decreased MAP >20 5. Hyperkalemia 6. Lactic Acidosis 7. Hypoxia 8. Feelings of impending doom

A client is in the compensatory stage of shock. What are some findings that indicate the client is entering the progressive stage of shock?

Continuously monitor BP

A client is receiving Dopamine Hydrochloride for treatment of shock. What action should the nurse take?

Clear the airway/provide suction.

A client who has had the jaws wired begins to vomit. What should the nurse do first?

Clean the area with normal saline solution & cover it with a protective dressing.

A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. What is the best action for the nurse to take?

ARDS

A client with sepsis begins having labored breathing, confusion, & lethargy. What complication should the nurse assess for?

24-48 hours after

Airway edema peaks ________-________ post burn injury. Patients may possibly have no symptoms before.

Spleen

Blunt abdominal injuries usually affect the ____________.

Greater than 35-45%

Burn patients should be intubated if greater than _______-________ % of their body surface is burned.

Calories & Protein

Burn patients should have diets high in ________________ & _____________.

100% O2 nonrebreather mask

During a primary trauma survey if the patient does not need to be intubated, what kind of airway support should they receive?

Increased Creatinine

During the emergent (resuscitative) phase of burn injury, an increased _______________ level indicates that the client requires additional volume with fluid resuscitation.

Cullen's Sign

Ecchymosis around the umbilicus that may indicate retroperitoneal bleeding.

Turner's Sign

Ecchymosis in the flank area (sides) that may indicate retroperitoneal bleeding.

Greater than 15-20%

Fluid resuscitation is done if greater than _______-______ % of the body surface area is burned.

APP = MAP - IAP

How do you calculate Abdominal Perfusion Pressure?

If they are hemodynamically unstable they will need surgery.

How does the nurse know if someone with spleen or liver trauma will likely need surgery or not?

"Good lung down"

How should patients with Pulmonary Contusions be positioned?

8

If a patient has a GCS score of ________ or less during a primary trauma survey they should be intubated because they are at risk for losing their airway.

Consult the urologist, catheters cannot be inserted.

If a trauma patient needs a catheter but has blood at the urinary meatus, what should the nurse do next?

Hyperactive

In PUD bowel sounds are initially ______________ but diminish with progression of the disorder.

Teeth, bones, vomit, & blood.

In patients with facial trauma, nurses should assess for potential airway obstructions such as __________, __________, __________, or ___________.

Autonomic Dysreflexia

Massive SNS activation in response to a noxious stimulus such as a full bladder or fecal impaction. Can occur as a complication after spinal cord injury & is life-threatening.

5,000 - 8,000 calories/day

Nutrition should be given ASAP to burn injury patients through Enteral feedings of about ________________________ calories/day.

External splints (ace wraps, etc.)

Patients with rib fractures should not have ____________________ applied.

Keep up with vaccinations.

Patients with spleen trauma should be taught to ______________________ in the future.

Liver

Penetrating abdominal injuries most commonly affect the ______________.

Edema & inflammation resolve.

Post-operative extubation in trauma patients should wait until after _____________ & ______________ resolves.

Kehr's Sign

Referred palpable left abdominal pain that may indicate ruptured spleen or foreign contents in the peritoneum.

3rd degree (full thickness)

The nurse determines that a patient's burns are dry & pale white with some areas that are brown & leathery. What type of burn is this?

Urine output 30-50 mL/hour.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. What finding indicates that adequate fluid replacement has been achieved?

Hypokalemia

The nurse should anticipate ______________ in burn patients undergoing fluid resuscitation.

Height & weight (to calculate body surface area)

The nurse should obtain a burn patient's ______________ & ______________ from before the injury occurred.

Weight & body surface area that was burned.

The rate at which IV fluids are infused is based on the burn client's _______________ & _______________.

1. Need PEEP to open alveoli. 2. Position unilateral (good lung down). 3. Semi-fowlers position with HOB elevated. 4. Turn, cough, & deep breathe.

What are some interventions for patients with pulmonary contusions?

True (because of potassium imbalances)

True or False: Burn victims are at increased risk for dysrhythmias.

True (follow the formula required to administer the saline & don't give additional bolus)

True or False: Fluid boluses should be avoided in burn victims secondary to risk of worsening edema.

1. Uneven legs 2. Turned foot

What are 2 signs that may indicate pelvic trauma?

1. Hemorrhage 2. Hollow organ perforation w/ secondary peritonitis 3. Sepsis

What are 3 major life-threatening concerns associated with abdominal trauma?

1. Spinal Shock 2. Neurogenic Shock 3. Autonomic Dysreflexia

What are 3 potential complications of Spinal Cord Injury?

1. NPO when symptoms are present. 2. IV antibiotics (Flagyl, Bactrim, Cipro). 3. Pain meds (Demerol or Morphine). 4. IV fluids, monitor hydration. 5. Assess for signs of Peritonitis (fever, ^RR, bloating).

What are interventions for the initial phase of Diverticulitis?

1. Place patient in upright sitting position** 2. Assess for & remove noxious stimuli (bladder or impaction) 3. Loosen any constrictive clothing (no TED hose). 4. Monitor BP every 10 minutes. 5. Anticipate antihypertensive meds.

What are nursing interventions used to help treat Autonomic Dysreflexia after a spinal cord injury?

1. Slowly start clear liquid diet at first. 2. Low fiber diet (white rice, cooked skinned fruit). 3. Insert NGT if there's N/V.

What are some Diverticulitis interventions for patients in the recovery phase when symptoms are beginning to improve?

1. Elevate HOB 2. Reverse Trendelenburg position (head up) 3. Avoid excess fluid 4. Vasopressors & Inotropic meds

What are some examples of interventions to help treat increased IAP?

1. Prevent constipation, document BM. 2. Daily checks for impaction. 3. Fluid management 4. Elevate HOB 5. Manage pain

What are some examples of nursing interventions to help prevent an increase in IAP after abdominal trauma?

1. Increased CVP 2. Beck's Triad** (JVD, Hypotension, muffled heart sounds) 3. Pulsus paradoxus (big fall in BP >10 on inspiration) 4. Decreased venous return & CO. 5. LOC changes.

What are some expected manifestations of a patient with cardiac tamponade after thoracic trauma?

-Hematemesis -Hematochezia (red blood in stool) -Melena (black blood in stool)

What are some hallmark signs of GI hemorrhage?

1.Monitor PT/INR & bleeding precautions. 2. Avoid coughing/straining/bending/lifting (avoid rupture) 3. Monitor LOC & reflexes. 4.Strict I&Os, weight, & abd. girth. 5. Diet low in protein if confused.** 6. Diet high in lean protein, low in Na, reduce fluids & seafood if not confused. 7.Elevate HOB

What are some interventions for a patient with Cirrhosis?

1. NPO initially then slowly introduce fluids, NO fats.** 2. Hydrate with IV, may need TPN if longterm. 3. NGT to remove stomach contents & reduce vomiting. 4. Keep patient sitting up. 5. Monitor glucose and I&O. 6. Give PPI, H2 blockers, & antacids. 7. Pain meds (avoid Morphine) 8. Diet that's bland with high protein & complex carbs (fruits/veggies/grains). Eat small meals. 9. Diet low in fat, sugar, & refined carbs.

What are some interventions for patients with Pancreatitis?

Needs surgery because abdominal contents can enter thoracic cavity & put pressure on the lungs.

What are some interventions for patients with a ruptured diaphragm?

1. Prevent hypoxia 2. Promote ventilation 3. Pain control

What are some interventions for patients with flail chest trauma?

1. Cover hole with petroleum gauze. 2. Tape 3 sides so air can still escape. 3. Chest tube management.

What are some interventions for patients with open pneumothorax?

1. Avoid external splints (ace wraps). 2. Promote deep breathing to prevent atelectasis. 3. Pain control.

What are some interventions for patients with rib fractures?